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In Mexico, the patients with CKD in hemodialysis, a large percentage of patients have a prolonged use of non-tunneled catheter as vascular access, most of the patients had catheter placed in an emergency room and did not have follow-up by nephrology. The KDOQI recommendations suggest changing non tunneled catheter to a tunneled catheter no later than a week, In our unit patients who arrive with a non-tunneled catheter are changed to a tunneled catheter. we have observed that a non-tunneled catheter with prolonged use causes marsupialization of the skin at the catheter entry site (see pic1), so it is not possible to perform the procedure with guidewire catheter exchange due to the risk of externalization of the catheter and wound dehiscence(see pic2), we performed a skinplasty technique on the entry site to be able to perform guidewire exchange technique and allows the same venotomy.
All patients present marzupialization of the skin at the catheter entry site. The tip position of the non tunneled catheter is verified by chest x-ray. We use Medtronic Palindrome catheter with symmetrical tip, the procedure is described below: Step 1; The catheter is opened and the guidewire is introduced approximately 20cm. The temporary catheter is removed leaving only the guidewire in the jugular vein. Step 2; Hemostasis is performed at the catheter exit site, a cut is made with a scalpel to subcutaneous cellular tissue in the marsupialized skin with a Kelly clamp skin plasty is performed and cutting the excess skin until making a buttonhole. Step 3: At this point, the catheter placement is carried out as usually done, the skin is sutured with 3-0 nylon filament, the positioning of the tip is verified with a chest x-ray.
The baseline characteristics of the 43 prevalent HD patients were assessed the frequency and percentages of the dichotomous and means with IQR in the quantitative variables, we use paired student test to compare blood flow non-tunnelled and tunneled catheters, the post-surgical complications of the procedure were analyzed.
43 patients were evaluated, with a mean age of 42.1, the average time on HD of the patients was 65 months, the time in months of use of non-tunneled catheter was 9.6 (IQR: 4-12), blood flow from the non-tunneled catheter with a mean 361ml/min (IQR: 350-380), 79% was placed in the right jugular vein and the rest in the left jugular, the main reasons the non tunneled catheter changed was 95.3% due to prolonged use, all patients presented marsupialization of the skin at the entry site of catheter, after the placement of the tunneled catheter and performing the skinplasty technique, the following clinical variables were measured, all the catheters were placed in the same entry site, only 2.3% of patients had bleeding of the surgical wound without clinical impact, none had surgical wound dehiscence after placement, the catheter tip was assessed by chest X-ray; 53% positioned at the junction of the vena cava and right atrium, 41% right atrium , a mean blood flow of 387.3ml/min compared to the non-tunneled catheter blood flow of 361ml/min (P=<0.05), mean number of days in operation of the catheter was 256 days.
The skin plasty technique of the marsupialization at the entry site of a non-tunneled catheter for prolonged use is a good option for placing the guidewire exchange catheter and preserving the same venotomy.